In 2005, 133 million americans were living with at least one chronic condition. In 2020, this number is expected to grow to 157 million. In 2005, sixty-three million
people had multiple chronic illnesses, and that number will reach eighty-one million in 2020.

Patients with co-morbidities are typically treated by multiple
clinicians working for different healthcare organizations. Care Coordination is necessary for the effective treatment of these patients and reducing costs. Effective Care Coordination can reduce the number of redundant tests and procedures, hospital admissions and readmissions, medical errors, and patient safety issues related to the lack of medication reconciliation.

According to a paper by Dennison and Hugues published in the Journal of Cardiovascular Nursing and titledProgress in Prevention Imperative to Improve Care Transitions for Cardiovascular Patients, direct communication between the hospital and primary care setting
occurred only 3 percent of the time. According to the same paper, at discharge, a summary was
provided only 12 percent of the time, and this occurrence remained
poor at 4 weeks post-discharge, with only 51 percent of practitioners
providing a summary. The paper concluded that this standard affected quality of care in 25 percent of follow-up visits.

Health Information Exchanges (HIEs) and emerging delivery models like
the Accountable Care Organization (ACO) and the Patient-Centered Medical
Home (PCMH) were designed to promote care coordination. However, according to an article by Furukawa et al. published in the August 2013 issue of Health Affairs and titled Hospital Electronic Health Information Exchange Grew Substantially In 2008–12:

In 2012, 51 percent of hospitals exchanged clinical
information with unaffiliated ambulatory care providers, but only
36 percent exchanged information with other hospitals outside
the organization. . . . In 2012 more than half of hospitals exchanged
laboratory results or radiology reports, but only about one-third of
them exchanged clinical care summaries or medication lists with
outside providers.

There are other obstacles to care coordination including the existing fee-for-service healthcare delivery model (as opposed to a value-based model), the lack of interoperability between healthcare information systems, and the lack of adoption of effective collaboration tools.

What Can We Learn From High Risk Operations in Other Industries?

Similar breakdowns in communication during shift handovers have also been observed in risky operating environments, sometimes with devastating consequences. In the aerospace industry, human factors research and training have played an important role in successfully addressing the issue. A research paper by Parke and Mishkin titled Best Practices in Shift Handover Communication: Mars Exploration Rover Surface Operationsincluded the following recommendations:

Two-way Communication, Preferably Face-to-Face. . . . Two-way communication enables the incoming worker to ask questions and rephrase the material to be handed over, so as to expose these differences [in mental model].

Face-to-Face Handovers with Written Support. Face-to-face handovers are improved if they are supported by structured written material—e.g., a checklist of items to convey, and/or a position log to review.

Content of Handover Captures Intent. Handover communication works best if it captures problems, hypotheses, and intent, rather than simply lists what occurred.

While the logistics of healthcare delivery does not always permit physical face-to-face communication between clinicians during transitions of care, the web has seen an explosion in online collaboration tools. Innovative organizations have embraced these technologies giving rise to a new breed of enterprise software known as Enterprise 2.0 or Social Enterprise Software. This new breed of software is not only social, but also mobile, and cloud-based.

Care Coordination in the Health Enterprise 2.0

Collaborative Authoring of a Longitudinal Care Plan. From a content
perspective, the Care Plan is the backbone of Care Coordination. The Care Plan should be comprehensive and standardized (similar to the checklist in aerospace operations). It should include problems, medications, orders, results, care goals (taking into consideration the patient's wishes and values), care team members and their responsibilities, and actual patient outcomes (e.g., functional status).
Clinical Decision Support (CDS) tools can be used to dynamically
generate a basic Care Plan based on the patient's specific clinical
data. This basic Care Plan can be used by members of the care team to
build a more elaborate Longitudinal Care Plan. CDS tools can also automatically generate
alerts and reminders for the care team.

Communication and Collaboration using Enterprise 2.0 Software. These tools should be used to enable collaboration between all members of the care team which include not only clinicians, but also non-clinician caregivers, and the patient herself. Beyond email, these tools allow conversations and knowledge sharing through instant messaging, video conferencing (for virtual two-way face-to-face communication), content management, file syncing (allowing the longitudinal care plan to be synchronized and shared among all members of the care team), search, and enterprise social networking (because clinical work is a social activity like most human activities). A providers directory should make it easy for users to find
a specific provider and all their contact information based on search criteria such as location,
specialty, knowledge, experience, and telephone number.

Light Weight Standards and Protocols for Content, Transport, Security, and Privacy. The foundation standards are: REST, JSON,
OAuth2, and OpenID Connect. An emerging approach that could really help put patients in control of the privacy of their electronic medical record is the OAuth2.0-based User-Managed Access (UMA) Protocol of the Kantara Initiative (see my previous post titled Patient Privacy at Web Scale). Initiatives like the ONC-sponsored RESTful Health Exchange (RHEX) project and the HL7 Fast Healthcare Interoperability Resources (FHIR) hold great promise.

Disclaimer

The opinions expressed in this blog are solely my own.

All information in this blog is provided "as is", with no guarantee of completeness, accuracy, timeliness or of the results obtained from the use of this information, and without warranty of any kind, express or implied, including, but not limited to warranties of performance, merchantability and fitness for a particular purpose.